Clinical Review of Hypertensive Acute Heart Failure

Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.

Sudden cardiac death in long-term follow-up in patients treated with primary percutaneous coronary intervention

Objective. Most studies analyzing predictors of sudden cardiac death (SCD) after acute myocardial infarction included only high-risk patients or index reperfusion had not been performed in all patients. The aim of our study was to analyze the incidence of SCD and determine the predictors of SCD occurrence during 6-year follow-up of unselected patients with ST-elevation myocardial infarction (STEMI), treated with primary percutaneous coronary intervention (pPCI). Method. we analysed 3114 STEMI patients included included in the University Clinical Center of Serbia STEMI Register. Patients presenting with cardiogenic schock were excluded. Echocardiographic examination was performed before hospital discharge. Results. During 6-year follow-up, lethal outcome was registered in 297 (9.5%) patients, of whom 95 (31.9%) had SCD. The highest incidence of SCD was recorded in the first year of follow-up, when SCD was registered in 25 patients, which is 26.3% of the total number of patients who had had SCD, i.e. 0.8% of the patients analyzed. The independent predictors for the occurrence of SCD during 6-year follow-up were EF < 45% (HR 3.07, 95% 1.87-5.02), post-procedural TIMI flow <3 (HR 2.59, 95%CI 1.37-5.14), reduced baseline kidney function (HR 1.87, 95%CI 1.12-2.93) and Killip class >1 at admission (HR 1.69, 95%CI 1.23-2.97). Conclusion. There is a low incidence of SCD in unselected STEMI patients treated with primary PCI. Predictors of SCD occurence during long-term follow-up in analyzed patients are clinical variables that are easily recorded during index hospitalization and include: EF ≤45%, post-procedural flow TIMI < 3, Killip class >1, and reduced baseline kidney function.

The follow-up of myocardial injury and left ventricular function after spontaneous coronary artery dissection

Monitoring patients with spontaneous coronary dissection (SCAD) is critical in their care, as there are no accepted recommendations. To this end, finding clinical or imaging predictors of recurrent events in these patients is essential for predicting adverse events and guiding treatment decisions between conservative medical therapy and percutaneous coronary intervention. Myocardial injury and left ventricular function after SCAD can be variable parameters that require monitoring. Echocardiography and cardiac magnetic resonance are two useful imaging techniques to do so. This review aims to analyze previously published results on monitoring myocardial injury and left ventricular function in SCAD patients while highlighting the potential benefits of contemporary imaging techniques that could further improve patient care in the future.

GPX3 Variant Genotype Affects the Risk of Developing Severe Forms of COVID-19

In SARS-CoV-2 infection, excessive activation of the immune system intensively increases reactive oxygen species levels, causing harmful hyperinflammatory and oxidative state cumulative effects which may contribute to COVID-19 severity. Therefore, we assumed that antioxidant genetic profile, independently and complemented with laboratory markers, modulates COVID-19 severity. The study included 265 COVID-19 patients. Polymorphism of GSTM1, GSTT1, Nrf2 rs6721961, GSTM3 rs1332018, GPX3 rs8177412, GSTP1 rs1695, GSTO1 rs4925, GSTO2 rs156697, SOD2 rs4880 and GPX1 rs1050450 genes was determined with appropriate PCR-based methods. Inflammation (interleukin-6, CRP, fibrinogen, ferritin) and organ damage (urea, creatinine, transaminases and LDH) markers, complete blood count and coagulation status (d-dimer, fibrinogen) were measured. We found significant association for COVID-19 progression for patients with lymphocytes below 1.0 × 109/L (OR = 2.97, p = 0.002). Increased IL-6 and CRP were also associated with disease progression (OR = 8.52, p = 0.001, and OR = 10.97, p < 0.001, respectively), as well as elevated plasma AST and LDH (OR = 2.25, p = 0.021, and OR = 4.76, p < 0.001, respectively). Of all the examined polymorphisms, we found significant association with the risk of developing severe forms of COVID-19 for GPX3 rs8177412 variant genotype (OR = 2.42, p = 0.032). This finding could be of particular importance in the future, complementing other diagnostic tools for prediction of COVID-19 disease course.

Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

Although the frequency of myocarditis in the general population is very difficult to accurately determine due to the large number of asymptomatic cases, the incidence of this disease is increasing significantly due to better defined criteria for diagnosis and the development of modern diagnostic methods. The multitude of different etiological factors, the diversity of the clinical picture, and the variability of the diagnostic findings make this disease often demanding both for the selection of the diagnostic modality and for the proper therapeutic approach. The previously known most common viral etiology of this disease is today overshadowed by new findings based on immune-mediated processes, associated with diseases that in their natural course can lead to myocardial involvement, as well as the iatrogenic cause of myocarditis, which is due to use of immune checkpoint inhibitors in the treatment of cancer patients. Suspecting that a patient with polymorphic and non-specific clinical signs and symptoms, such as changes in ECG and echocardiography readings, has myocarditis is the starting point in the diagnostic algorithm. Cardio magnetic resonance imaging is non-invasive and is the gold standard for diagnosis and clinical follow-up of these patients. Endomyocardial biopsy as an invasive method is the diagnostic choice in life-threatening cases with suspicion of fulminant myocarditis where the diagnosis has not yet established or there is no adequate response to the applied therapeutic regimen. The treatment of myocarditis is increasingly demanding and includes conservative methods of treating heart failure, immunomodulatory and immunospressive therapy, methods of mechanical circulatory support, and heart transplantation. The goal of developing new diagnostic and therapeutic methods is to reduce mortality from this complex disease, which is still high.

Prognostic Impact of Non-Cardiac Comorbidities on Long-Term Prognosis in Patients with Reduced and Preserved Ejection Fraction following Acute Myocardial Infarction

BACKGROUND

We aimed to analyze the prevalence and long-term prognostic impact of non-cardiac comorbidities in patients with reduced and preserved left-ventricular ejection fraction (EF) following ST-elevation myocardial infarction (STEMI).

METHOD

A total of 3033 STEMI patients undergoing primary percutaneous coronary intervention (pPCI) were divided in two groups: reduced EF < 50% and preserved EF ≥ 50%. The follow-up period was 8 years.

RESULTS

Preserved EF was present in 1726 (55.4%) patients and reduced EF was present in 1389 (44.5%) patients. Non-cardiac comorbidities were more frequent in patients with reduced EF compared with patients with preserved EF (38.9% vs. 27.4%, respectively, p < 0.001). Lethal outcome was registered in 240 (17.2%) patients with reduced EF and in 40 (2.3%) patients with preserved EF, p < 0.001. Diabetes and chronic kidney disease (CKD) were independent predictors for 8-year mortality in patients with preserved EF. In patients with reduced EF, CKD was independently associated with 8-year mortality.

CONCLUSION

In patients who had reduced EF, the prevalence of non-cardiac comorbidities was higher than in patients who had preserved EF after STEMI. Only diabetes mellitus and CKD were independently associated with 8-year mortality in analyzed patients.

Antioxidant Genetic Variants Modify Echocardiography Indices in Long COVID

Although disturbance of redox homeostasis might be responsible for COVID-19 cardiac complications, this molecular mechanism has not been addressed yet. We have proposed modifying the effects of antioxidant proteins polymorphisms (superoxide dismutase 2 (SOD2), glutathione peroxidase 1 (GPX1), glutathione peroxidase 3 (GPX3) and nuclear factor erythroid 2-related factor 2, (Nrf2)) in individual susceptibility towards the development of cardiac manifestations of long COVID-19. The presence of subclinical cardiac dysfunction was assessed via echocardiography and cardiac magnetic resonance imaging in 174 convalescent COVID-19 patients. SOD2, GPX1, GPX3 and Nrf2 polymorphisms were determined via the appropriate PCR methods. No significant association of the investigated polymorphisms with the risk of arrhythmia development was found. However, the carriers of variant GPX1*T, GPX3*C or Nrf2*A alleles were more than twice less prone for dyspnea development in comparison with the carriers of the referent ones. These findings were even more potentiated in the carriers of any two variant alleles of these genes (OR = 0.273, and p = 0.016). The variant GPX alleles were significantly associated with left atrial and right ventricular echocardiographic parameters, specifically LAVI, RFAC and RV-EF (p = 0.025, p = 0.009, and p = 0.007, respectively). Based on the relation between the variant SOD2*T allele and higher levels of LV echocardiographic parameters, EDD, LVMI and GLS, as well as troponin T (p = 0.038), it can be proposed that recovered COVID-19 patients, who are the carriers of this genetic variant, might have subtle left ventricular systolic dysfunction. No significant association between the investigated polymorphisms and cardiac disfunction was observed when cardiac magnetic resonance imaging was performed. Our results on the association between antioxidant genetic variants and long COVID cardiological manifestations highlight the involvement of genetic propensity in both acute and long COVID clinical manifestations.

Chronic or Changeable Infarct Size after Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) could be the cause of acute myocardial infarction (AMI) and sudden cardiac death. Clinical presentations can vary considerably, but the most common is the elevation of cardiac biomarkers associated with chest discomfort. Different pathological etiology in comparison with Type 1 AMI is the underlying infarct size in this population. A 42-year-old previously healthy woman presented with SCAD. Detailed diagnostical processing and treatment which were performed could not prevent myocardial injury. The catheterization laboratory was the initial place for the establishment of a diagnosis and proper management. The management process can be very fast and sometimes additional imaging methods are necessary. Finding predictors of SCAD recurrence is challenging, as well as predictors of the resulting infarct scar size. Patients with recurrent clinical symptoms of chest pain, ST elevation, and complication represent a special group of interest. Therapeutic approaches for SCAD range from the "watch and wait" method to complete revascularization with the implantation of one or more stents or aortocoronary bypass grafting. The infarct size could be balanced through the correct therapeutical approach, and, proper multimodality imaging would be helpful in the assessment of infarct size.

Coronary Microcirculation: The Next Frontier in the Management of STEMI

Although the widespread adoption of timely invasive reperfusion strategies over the last two decades has significantly improved the prognosis of patients with ST-segment elevation myocardial infarction (STEMI), up to half of patients after angiographically successful primary percutaneous coronary intervention (PCI) still have signs of inadequate reperfusion at the level of coronary microcirculation. This phenomenon, termed coronary microvascular dysfunction (CMD), has been associated with impaired prognosis. The aim of the present review is to describe the collected evidence on the occurrence of CMD following primary PCI, means of assessment and its association with the infarct size and clinical outcomes. Therefore, the practical role of invasive assessment of CMD in the catheterization laboratory, at the end of primary PCI, is emphasized, with an overview of available technologies including thermodilution- and Doppler-based methods, as well as recently developing functional coronary angiography. In this regard, we review the conceptual background and the prognostic value of coronary flow reserve (CFR), index of microcirculatory resistance (IMR), hyperemic microvascular resistance (HMR), pressure at zero flow (PzF) and angiography-derived IMR. Finally, the so-far investigated therapeutic strategies targeting coronary microcirculation after STEMI are revisited.

The Impact of Kidney Function on the Slow-Flow/No-Reflow Phenomenon in Patients Treated with Primary Percutaneous Coronary Intervention: Registry Analysis

OBJECTIVE

The objective of this study is to analyze the impact of declining kidney function on the occurrence of the slow-flow/no-reflow phenomenon in patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI (pPCI), as well as the analysis of the prognostic impact of the slow-flow/no-reflow phenomenon on short- and long-term mortality in these patients.

METHODS

We analyzed 3,115 consecutive patients. A value of the glomerular filtration rate (eGFR) at the time of admission of eGFR <90 ml/min/m2 was considered a low baseline eGFR. The follow-up period was 8 years.

RESULTS

The slow-flow/no-reflow phenomenon through the IRA was registered in 146 (4.7%) patients. Estimated GFR of <90 ml/min/m2 was an independent predictor for the occurrence of the slow-flow/no-reflow phenomenon (OR 2.91, 95% CI 1.25-3.95, p < 0.001), and the risk for the occurrence of the slow-flow/no-reflow phenomenon increased with the decline of the kidney function: eGFR 60-89 ml/min/m2: OR 1.94 (95% CI 1.22-3.07, p = 0.005), eGFR 45-59 ml/min/m2: OR 2.55 (95% CI 1.55-4.94, p < 0.001), eGFR 30-44 ml/min/m2: OR 2.77 (95% CI 1.43-5.25, p < 0.001), eGFR 15-29 ml/min/m2: OR 5.84 (95% CI 2.84-8.01, p < 0.001). The slow-flow/no-reflow phenomenon was a strong independent predictor of short- and long-term all-cause mortality: 30-day mortality (HR 2.62, 95% CI 1.78-3.57, p < 0.001) and 8-year mortality (HR 2.09, 95% CI 1.49-2.09, p < 0.001).

CONCLUSION

Reduced baseline kidney function was an independent predictor for the occurrence of the slow-flow/no-reflow phenomenon, and its prognostic impact started with the mildest decrease in eGFR (below 90 ml/min/m2) and increased with its further decline. The slow-flow/no-reflow phenomenon was a strong independent predictor of mortality in the short- and long-term follow-up of the analyzed patients.

Case report: Acute toxic myocardial damage caused by 5-fluorouracil—from enigma to success

Considering the pandemic of both cardiovascular diseases and oncological diseases, there is an increasing need for the use of chemotherapy, which through various pathophysiological mechanisms leads to damage to heart function. Cardio toxicity of chemotherapy drugs can manifest itself in a variety of clinical manifestations, which is why establishing a valid diagnosis is a real mystery for clinicians. Acute systolic heart failure (AHF) due to the use of 5-fluorouracil (5-FU) is a rare occurrence if it is not associated with myocardial infarction, myocarditis or Takotsubo cardiomyopathy. Therefore, we decided to present a case of an 52-year-old male who was diagnosed with stage IV RAS wild-type adenocarcinoma of the rectum and in whom the direct toxic effect 5-FU is the main reason for the appearance of toxic cardiomyopathy.

Women in cardiology leadership of randomized clinical trials and participation of women in late-breaking clinical trials: has the COVID-19 pandemic changed a thing or not exactly?

Introduction

Despite considerable developments made in the representation of women in cardiology (WIC) recently, there still remain substantial disparities in the representation of women participants in clinical trials, as well as women physicians and scientists in clinical trial leadership. Under-representation of women in Randomized Clinical Trials (RCTs) remains the bane of the modern medicine, impeding the development of sex-specific guidelines in cardiovascular diseases. Female leadership in clinical trials has been shown to enhance the inclusion of women as trial participants. Furthermore, while the COVID-19 pandemic has impacted women in academia, there is no data thus far reporting the impact of the pandemic in terms of presenters and leadership of late-breaking clinical trials (LBCT) in cardiology during this period.

Purpose

We aimed to determine inclusion of WIC in LBCTs leadership and their correlation to inclusion of women in reported RCTs.

Methods

In our comprehensive analysis, we included all LBCTs presented at major international cardiovascular meetings reported over the period of January 2020 to February 2022. Data were derived from the original presentation at the meeting and/or simultaneous/ subsequent publication of manuscript. Sex of the presenter (woman or man), was assessed by either original videos of the presentation at the meeting, or based on pronoun use in the biographies derived from institutional profiles. The presence or absence of reporting of sex distribution of study participants were also recorded from original presentation at the meeting and/or published manuscript. Proportion of women included in each trial was sourced from either original publication or calculated from any similar data shown during the presentations.

Results

A total of 400 of RCTs from 19 meetings were included with a total of 400 presenters/principal investigators recorded – 32 (8%) women and 368 (92%) men. There were no significant differences between 2020 and 2021 [15 (7.2%) women in 2021 vs. 17 (19.3%) in 2020 (P=0.446)]. Proportions of women included in RCTs with WIC (37.3%) vs. non-WIC (38.7%) presenters were comparable (p=0.559), while 45% of RCTs didn't report sex distribution of participants. Except for 2 meetings (CRT 2020 and 2022), all others were virtual.

Conclusion

WIC representation as RCTs presenters was significantly low, despite the opportunity of virtual attendance afforded during the COVID-19 pandemic. Modest inclusion of women irrespective of sex of RCT leadership emphasizes multi-level problems that require more actionable solutions: i.e. implicit bias training started as early as medical school, continuing education on necessity for diversity, equity and inclusion, patient and public involvement, and comprehensive guidance on trial design, such that future RCT participants reflect the populations intended to treat.

Funding Acknowledgement

Type of funding sources: None.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Acute Coronary Syndrome in the COVID-19 Era-Differences and Dilemmas Compared to the Pre-COVID-19 Era

The COVID-19 pandemic has led to numerous negative implications for all aspects of society. Although COVID-19 is a predominant lung disease, in 10-30% of cases, it is associated with cardiovascular disease (CVD). The presence of myocardial injury in COVID-19 patients occurs with a frequency between 7-36%. There is growing evidence of the incidence of acute coronary syndrome (ACS) in COVID-19, both due to coronary artery thrombosis and insufficient oxygen supply to the myocardium in conditions of an increased need. The diagnosis and treatment of patients with COVID-19 and acute myocardial infarction (AMI) is a major challenge for physicians. Often the presence of mixed symptoms, due to the combined presence of COVID-19 and ACS, as well as possible other diseases, nonspecific changes in the electrocardiogram (ECG), and often elevated serum troponin (cTn), create dilemmas in diagnosing ACS in COVID-19. Given the often-high ischemic risk, as well as the risk of bleeding, in these patients and analyzing the benefit/risk ratio, the treatment of patients with AMI and COVID-19 is often associated with dilemmas and difficult decisions. Due to delays in the application of the therapeutic regimen, complications of AMI are more common, and the mortality rate is higher.

SOD2 rs4880 and GPX1 rs1050450 polymorphisms do not confer risk of COVID-19, but influence inflammation or coagulation parameters in Serbian cohort

Objectives: Due to the role of oxidative stress in the pathophysiology of COVID-19, it is biologically plausible that inter-individual differences in patients' clinical manifestations might be affected by antioxidant genetic profile. The aim of our study was to assess the distribution of antioxidant genetic polymorphisms Nrf2 rs6721961, SOD2 rs4880, GPX1 rs1050450, GPX3 rs8177412, and GSTP1 (rs1695 and rs1138272) haplotype in COVID-19 patients and controls, with special emphasis on their association with laboratory biochemical parameters.Methods: The antioxidant genetic polymorphisms were assessed by appropriate PCR methods in 229 COVID-19 patients and 229 matched healthy individuals.Results: Among examined polymorphisms, only GSTP1 haplotype was associated with COVID-19 risk (p = 0.009). Polymorphisms of SOD2 and GPX1 influenced COVID-19 patients' laboratory biochemical profile: SOD2*Val allele was associated with increased levels of fibrinogen (p = 0.040) and ferritin (p = 0.033), whereas GPX1*Leu allele was associated with D-dimmer (p = 0.009).Discussion: Our findings regarding the influence of SOD2 and GPX1 polymorphisms on inflammation and coagulation parameters might be of clinical importance. If confirmed in larger cohorts, these developments could provide a more personalized approach for better recognition of patients prone to thrombosis and those for the need of targeted antiox-idant therapy.

GSTO1, GSTO2 and ACE2 Polymorphisms Modify Susceptibility to Developing COVID-19

Based on the close relationship between dysregulation of redox homeostasis and immune response in SARS-CoV-2 infection, we proposed a possible modifying role of ACE2 and glutathione transferase omega (GSTO) polymorphisms in the individual propensity towards the development of clinical manifestations in COVID-19. The distribution of polymorphisms in ACE2 (rs4646116), GSTO1 (rs4925) and GSTO2 (rs156697) were assessed in 255 COVID-19 patients and 236 matched healthy individuals, emphasizing their individual and haplotype effects on disease development and severity. Polymorphisms were determined by the appropriate qPCR method. The data obtained showed that individuals carrying variant GSTO1*AA and variant GSTO2*GG genotypes exhibit higher odds of COVID-19 development, contrary to ones carrying referent alleles (p = 0.044, p = 0.002, respectively). These findings are confirmed by haplotype analysis. Carriers of H2 haplotype, comprising GSTO1*A and GSTO2*G variant alleles were at 2-fold increased risk of COVID-19 development (p = 0.002). Although ACE2 (rs4646116) polymorphism did not exhibit a statistically significant effect on COVID-19 risk (p = 0.100), the risk of COVID-19 development gradually increased with the presence of each additional risk-associated genotype. Further studies are needed to clarify the specific roles of glutathione transferases omega in innate immune response and vitamin C homeostasis once the SARS-CoV-2 infection is initiated in the host cell.

GSTP1 and GSTM3 Variant Alleles Affect Susceptibility and Severity of COVID-19

Based on the premise that oxidative stress plays an important role in severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection, we speculated that variations in the antioxidant activities of different members of the glutathione S-transferase family of enzymes might modulate individual susceptibility towards development of clinical manifestations in COVID-19. The distribution of polymorphisms in cytosolic glutathione S-transferases GSTA1, GSTM1, GSTM3, GSTP1 (rs1695 and rs1138272), and GSTT1 were assessed in 207 COVID-19 patients and 252 matched healthy individuals, emphasizing their individual and cumulative effect in disease development and severity. GST polymorphisms were determined by appropriate PCR methods. Among six GST polymorphisms analyzed in this study, GSTP1 rs1695 and GSTM3 were found to be associated with COVID-19. Indeed, the data obtained showed that individuals carrying variant GSTP1-Val allele exhibit lower odds of COVID-19 development (p = 0.002), contrary to carriers of variant GSTM3-CC genotype which have higher odds for COVID-19 (p = 0.024). Moreover, combined GSTP1 (rs1138272 and rs1695) and GSTM3 genotype exhibited cumulative risk regarding both COVID-19 occurrence and COVID-19 severity (p = 0.001 and p = 0.025, respectively). Further studies are needed to clarify the exact roles of specific glutathione S-transferases once the SARS-CoV-2 infection is initiated in the host cell.

Relative impact of acute heart failure and acute kidney injury on short- and long-term prognosis of patients with STEMI treated with primary PCI

Background

Although both acute heart failure (AHF) and acute kidney injury (AKI) have been separately recognized as contributors to an increased mortality risk in patients with ST-segment elevation myocardial infarction (STEMI), their relative importance has not been extensively studied.

Purpose

Our aim was to investigate the relative impact of AHF and AKI on 30-day and 5-year mortality following primary PCI for STEMI.

Methods

8 054 patients referred to primary PCI during the years 2009–2019, and with the available repeated creatinine measurements, were analyzed. AKI was defined as ≥25% relative or ≥0.5 mg/dl absolute rise in creatinine from baseline, within 72 hours of intervention. Acute heart failure was defined as Killip class ≥2 on admission to hospital. Cox regression model was used to assess the effect of the interaction of AHF and AKI on mortality. Median follow-up was 5 years.

Results

The incidence of AKI was 9.9% (n=805) and of AHF 12.3% (n=1050). Concurrence of AHF and AKI was noted in 1.7% of the included patients (n=315). The combined presence of AHF and AKI significantly increased mortality both at 30 days (30.7%) and at 5 years (73.3%), as compared with AKI alone (8.2% at 30 days and 32.3% at 5 years) and AHF alone (13.0% and 53.0%). When adjusted for other significant predictors, such as age, prior stroke, hyperlipidemia, atrial fibrillation, ejection fraction, final TIMI flow in the culprit artery, the use of intra-aortic balloon pump and multivessel disease, both AKI and AHF were independently associated with mortality. The adjusted relative impact of AKI on mortality was stronger than that of AHF at 30 days (adjusted HR 3.5 and 2.2, respectively), whereas it was comparable at 5 years (adjusted HR 1.3 and 1.4, respectively). Furthermore, the combined presence of AHF on admission and the post-primary PCI development of AKI was associated with the highest magnitude of risk at both 30 days (HR 5.0, CI95% 3.0–8.3, p&lt;0.001) and 5 years (HR 2.4, CI95% 1.83–3.16, p&lt;0.001).

Conclusion

Acute kidney injury following primary PCI for STEMI was associated with a higher adjusted risk of short-term mortality when compared with acute heart failure, whereas their relative impact was comparable in the long-term.

Funding Acknowledgement

Type of funding sources: None.

Impact of kidney function on the occurrence of new-onset atrial fibrillation in patients with ST-elevation myocardial infarction

OBJECTIVE

In this study, we aimed to examine the prognostic impact of decreased kidney function at admission on the occurrence of new-onset atrial fibrillation (AF) in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI).

METHODS

The study enrolled 3,115 consecutive patients with STEMI. Kidney function was assessed by estimation of the glomerular filtration rate (eGFR) at admission. Patients with cardiogenic shock at admission, patients on hemodialysis, and patients with a medical history of previous AF (paroxysmal, persistent, or permanent) were excluded. The follow-up period was six years.

RESULTS

New-onset AF occurred in 215 (6.9%) patients, 75 (34.9%) patients presented with AF, and 140 (65.1%) patients developed AF after pPCI. The median time of AF occurrence in patients who did not present with AF was 4.5 (interquartile range 1-25) hours after pPCI. New-onset AF was associated with a higher short- and long-term mortality. In the multiple logistic regression analysis, all stages of reduced kidney function were independent predictors for the occurrence of new-onset AF, and negative prognostic impact increased with the deterioration of kidney function: eGFR <90 mL/min/m2, hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.42-2.89, p=0.011; eGFR 60-89 mL/min/m2, HR 1.54, 95% CI 1.13-2.57, p=0.045; eGFR 45-59 mL/min/m2-, HR 2.09, 95% CI 1.24-2.85, p=0.023; eGFR 30-44 mL/min/m2-, HR 2.93, 95% CI 1.64-5.29, p<0.001; eGFR 15-29 mL/min/m2-, HR 5.51, 95% CI 2.67-11.39, p<0.001.

CONCLUSION

Decreased kidney function was significantly associated with the occurrence of new-onset AF, and its impact increased with the deterioration in kidney function, starting with an eGFR value of 90 mL/min/m2. New-onset AF was an independent predictor of long-term all-cause mortality in the analyzed patients.

Smoking and sex differences in first manifestation of cardiovascular disease

BACKGROUND AND AIMS

An increasing proportion of women believe that smoking few cigarettes daily substantially reduces their risk of developing cardiovascular (CV) related disorders. The effect of low intensity smoking is still largely understudied. We investigated the relation among sex, age, cigarette smoking and ST segment elevation myocardial infarction (STEMI) as initial manifestation of CV disease.

METHODS

We analyzed data of 50,713 acute coronary syndrome patients with no prior manifestation of CV disease from the ISACS-Archives (NCT04008173) registry. We compared the rates of STEMI in current smokers (n = 11,530) versus nonsmokers (n = 39,183).

RESULTS

In the young middle age group (<60 years), there was evidence of a more harmful effect in women compared with men (RR ratios: 1.90; 95% CI: 1.69-2.14 versus 1.68; 95% CI: 1.56-1.80). This association persisted even in women who smoked 1 to 10 packs per year (RR ratios: 2.02; 95% CI: 1.65 to 2.48 versus 1.38; 95% CI: 1.22 to 1.57). In the older group, rates of STEMI were similar for women and men (RR ratios: 1.36; 95% CI: 1.22-1.53 versus 1.39; 95% CI: 1.28-1.50). STEMI was associated with a twofold higher 30-day mortality rate in young middle age women compared with men of the same age (odds ratios, 5.54; 95% CI, 3.83-8.03 vs. 2.93; 95% CI, 2.33-3.69).

CONCLUSIONS

Low intensity smoking provides inadequate protection in young - middle age women as they still have a substantially higher rate of STEMI and related mortality compared with men even smoking less than 10 packs per year. This finding is worrying as more young - middle age women are smoking, and rates of smoking among young-middle age men continue to fall.

Prognostic impact of non-culprit chronic total occlusion over time in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

AIMS

Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI.

METHODS AND RESULTS

The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan-Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54-2.36; P < 0.001] and late mortality (5-year adjusted HR 1.66, 95% CI 1.42-1.95; P < 0.001). Landmark analyses revealed an annual two-fold increase in mortality in patients with vs. without a CTO after the first year of follow-up. The observed pattern of mortality increase over time was independent of acute or chronic LV impairment.

CONCLUSIONS

Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

Gender Disparities on Access to Care and Coronary Disease Management

Mortality decline in women to a lesser extent than in men with coronary artery disease (CAD) has provoked a bigger interest in some already existing dilemmas and questions. Many studies carried out in the past three decades have remained without precise answers and with many challenges in the prevention, diagnosis, treatment and outcome of CAD in women. The meta-analysis and the systematic review conducted in the last years have offered novel approaches to understanding CAD gender disparities in access to care and coronary disease management in women, but women still were more likely to have experienced less favorable short- and long-term outcomes than men did. The reasons for these findings should lie in several known segments in the CAD pathophysiological mechanisms different in women and ultimately leading to a lower quality of care. Clinical presentation in women, which is often characterized by atypical chest pain and a higher prevalence of non-obstructive CAD when evaluated invasively, places women to the false-negative diagnosis of CAD and influences inadequate access to care. Clinical presentation and diagnostic methods, as well as the appropriate treatment options insufficiently examined in women, need to be better defined. The traditional risk factors and the cardiovascular risk factors unique in women have recently been recognized to have a greater impact on women. However, it is important to note, that even in women with obstructive CAD and typical clinical presentation invasive therapy and pharmacologic therapy is not always implemented as recommended by guidelines as in men. Women are underrepresented in CAD trials and, in current guidelines, gender differences in CAD management have not yet been justified. The underestimation of the risk of CAD in women, followed by its underdiagnosis and undertreatment, might be one of the reasons for a worse prognosis in women in comparison with men.

Myocardial deformation imaging in early prediction of heart failure development after STEMI is better than conventional echocardiography: true or false?

Funding Acknowledgements

Type of funding sources: None.

onbehalf

PREDICT-VT

Heart failure (HF) still develops in 4% up to 28% of STEMI pts treated by pPCI, with the highest incidence in the first year.  Accurate and early identification of high-risk patients would allow targeted and personalized intensive treatment .

Aim

the current study is a sub-study of PREDICT-VT study (NCT03263949). Its aim is to define multi-parametric model for early HF prediction in STEMI patients treated by pPCI, based on clinical data, conventional echocardiographic data and data from myocardial deformation analysis obtained by early speckle tracking echocardiography.

Methods

in 307 consecutive pts enrolled in PREDICT-VT, early echocardiography (5 ± 2 days after pPCI) was done and included LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec). LV indices of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains were also calculated .

Results

From 242 patients who completed 1-year follow-up, 9 % develop HF NYHA class 3 or 4, 27 % NYHA class 2 and remaining 64% were in NYHA class I. Significant univariate NYHA predictors were: from clinical parameters - female gender (ß =0.156, p = 0.015; 95% CI -0.431 to – 0.047), older age (ß =0.130, p = 0.044; 95% CI 0.000 to 0.017), Killip class on admission (ß=0.131, p = 0.043; 95% CI 0.007 to 0.435) and previous atrial fibrillation (ß=0.181, p = 0.005; 95% CI 0.175 to 0.960); from conventional echo parameters- LVEF (ß=-0.302, p &lt; 0.001; 95% CI -0.029 to -0.012), LAVI (ß=0.134, p = 0.046; 95%CI 0.000 to 0.030), degree of diastolic dysfunction (ß=0.297, p &lt; 0.001; 95% CI 0.192 to 0.465) and TAPSE (ß=-4.255, p &lt; 0.001); from parameters of longitudinal LV deformation – peak systolic epicardial LS  (ß=0.293, p &lt; 0.001; 95% CI 0.030 to 0.074), SRs (ß=0.274, p &lt; 0.001; 95% CI 0.398 to 1.069) and epicardial PSS (ß=0.336, p &lt; 0.001; 95%CI 0.925 to 2.019); from parameters of LV circumferential deformation – peak systolic endocardial CS (ß=0.254, p &lt; 0.001; 95% CI 0.013 to 0.041), SR E (ß= -0.247, p &lt; 0.001; 95%CI -0.556 to -0.173) and epicardial PSS CS (ß=0.206, p = 0.003; 95% CI 0.302 to 1.473); from left atrial mechanics - LA strain (ß=-0.231, p = 0.001; 95% CI -0.025 to -0.007).

Predictive power of model based on clinical variables (Killip class on admission, female gender, and history of atrial fib) for HF development was significantly improved when conventional ehocardiographic variables were added (LVEF, TAPSE, degree of diastolic function) (R2 from 0.076 to 0.197, p &lt; 0.001). However, addition of MDI parameters (longitudinal and cirumferential PSS on epicardial levels) increased it further (R2 from 0.200 to 0.229, p &lt; 0.001).

Conclusion

above from clinical and conventional echocardiographic parameters, amount of left ventricular post-systolic deformation in longitudinal and circumferential directions, expressed as LV indexes of post-systolic shortening, significantly improved early prediction of HF after pPCI.

Left ventricular and left atrial deformation imaging early after pPCI: does diabetes mellitus make any difference?

Funding Acknowledgements

Type of funding sources: None.

onbehalf

PREDICT-VT

More extensive coronary atherosclerosis in diabetes mellitu (DM) induces poorer clinical outcomes after STEMI, but there are data suggesting that impaired myocardial function in DM, even independently from epicardial coronary lesions severity, might have detrimental effect, predominately on heart failure development in DM.

Aim

the current study is a sub-study of PREDICT-VT study (NCT03263949), aimed to analyse LV and LA function using myocardial deformation imaging based on speckle tracking echocardiography after pPCI in STEMI patients with and without DM.

Methods

in 307 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done including LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec), LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains and analysis of LV rotation mechanic.

Results

from 242 patients who completed 1 year follow up, 48 (20%) had DM. Pts with DM were older (60 ± 1,01 vs 57 ± 10; p = 0.067) and had insignificantly higher SYNTAX score (18.5 ± 9.2 vs 15.8 ± 9.8, p = 0.118) . However, diabetics had more severely impaired EF (44.2 ± 8.6 vs 49.2 ± 9.8, p = 0.001), E/A ratio (0.78 ± 0.33 vs 0.90 ± 0.34; p = 0.036) and MAPSE (1.18 ± 0.32 vs 1.32 ± 0.33; p = 0.001).  Global LV LS on all layers (endo: -13.6 ± 4.0 vs-16.2 ± 4.7; mid: -11.9 ± 3.5 vs -14.1 ± 4.1; epi: -10.4 ± 3.1 vs -12.3 ± 3.6; p &lt; 0.005 for all) was impaired in DM patients, as well as longitudinal systolic SR (-0.71 ± 0.23 vs -0.84 ± 0.24; p = 0.001) and SR during early diastole (0.65 ± 0.26 vs 0.83 ± 0.33, p &lt; 0.001). Patients with DM had more pronounced longitudinal posts-systolic shortening throughout LV wall (endo: 21.4 ± 16.1 vs 13.7 ± 13.3, p = 0.005; mid: 21.9 ± 16.1 vs 14.3 ± 13.1, p = 0.006; epi: 22.4 ± 16.5 vs 15.3 ± 13.7, p = 0.010) and higher LV mechanical dispersion (MDI: 71.3 ± 38.3 vs 59.0 ± 18.9, p = 0.037). LA strain was significantly impaired in DM patients (18.9 ± 7.7 vs 22.6 ± 10.0, p = 0.011) and even more profoundly LA strain rate during early diastole (-0.73 ± 0.48 vs -1.00 ±0.58, p = 0.002). Patients with DM also had more impaired LV global (15.7 ± 9.1 vs 19.8 ± 10.4, p = 0.013) radial strain, global LV circumferencial strain, especially at the mid-wall level (-13.9 ± 4.2 vs -16.0 ± 4.3, p = 0.005) and impaired circumferential SR E (1.25± 0.44 vs 1.49 ± 0.46, p = 0.003). End-systolic rotation of the LV apex was more impaired in DM (4.7 ± 5.1 vs 6.8 ± 5.5, p= 0.022). During 1 year follow-up heart failure and all-cause mortality tend to be higher among DM pts (46.7% vs 35.2%, p = 0.153).

Conclusion

STEMI patients with DM have more severely impaired LV systolic and diastolic function estimated both by traditional parameter and advanced echo techniques. These results might, at least partially, explain why outcomes after STEMI in DM might be poorer, even in the absence of more complex angiographic findings, pointing to the significance of impaired myocardial function DM itself.

Can analysis of myocardial mechanic help me to predict heart failure development in my STEMI patient whose EF is equal or above 50% after pPCI?

Funding Acknowledgements

Type of funding sources: None.

onbehalf

PREDICT-VT

In spite of contemporary STEMI management, heart failure (HF) develops in 4% up to 28% of pPCI-treated patients, with the highest incidence in the first year.  Left ventricular ejection fraction (EF) is strong predictor predominately for HFrEF development, but risk stratification in case of preserved post pPCI EF (i.e. EF ≥ 50%) is still challenging.

Aim

the current study is a sub-study of PREDICT-VT study (NCT03263949). Its aim is to define clinical and "echocardiographic" profile of STEMI patient at risk to develop HF despite preserved post pPCI EF, including not only conventional echocardiographic data, but data from myocardial mechanic analysis obtained by early speckle tracking echocardiography.

Methods

in 307 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done and included LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec), calculation of LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains and thorough analysis of LV rotation mechanic.

Results

From 242 patients who completed 1-year follow-up, 109 pts (45 %) had post pPCI EF ≥50%. Of those patients 34 (31%) became NYHA ≥ 2 or died during 1-year follow-up (MACE+ group). Patients with MACE were older (63 ± 8 vs 55 ± 10, p &lt; 0.001), more frequently were female (47% vs 27%; p = 0.036) and more frequently had hypertension (40% vs 20%; p = 0.025). There were no significant differences in LV EF ( 56.5 ± 4.8% vs 56.3 ± 4.8 %; p = 0.849) and from conventional echo parameters only differences in E/A ratio (0.75 ± 0.24 vs 0.92 ± 0.32; p = 0.015) and MAPSE (1.54 ± 0.40 vs 1.36 ±0.27; p = 0.015) reached statistical significance. Surprisingly, there were no significant differences neither in LV longitudinal, nor circumferential deformations. However, LV radial deformation was significantly impaired in MACE+ pts both during systole (global radial strain: 16.4 ± 7.1 vs 21.1 ± 10.3; p = 0.008; end-systolic radial strain 13.1 ± 7.3 vs 18.1 ± 9.9; p = 0.005), early (radial SR E: -1.27 ± 0.66 vs 1.59 ± 0.79; p = 0.044) and late (radial SR A: -0.94 ± 0.41 vs -1.20 ± 0.59, p = 0.011) diastole. LV rotation was not significantly impaired, but slowed and delayed both during systole (time to peak systolic apical rotation (ms) 168 ± 86 vs 128 ± 70; p = 0.022) and diastole (rotation rate of LV base during early diastole (°/sec): 38.3 ± 27.4 vs 55.0 ± 31.5, p = 0.008; time to maximal LV untwisting rate (ms) 580 ± 210 vs 484 ± 154; p = 0.044), despite no differences in HR.

Conclusion

STEMI patients who will develop heart failure despite preserved post pPCI EF might have different clinical profile and different pattern of deviation in LV mechanic (predominately involving radial and rotational mechanic) and can be detected by contemporary echocardiographic techniques.

Prognostic impact of elevated baseline CRP levels in primary PCI-treated patients with residual cholesterol risk

Background

Recent large randomized studies have indicated the potential of anti-inflammatory therapies to reduce adverse cardiovascular events in patients with myocardial infarction, with the most pronounced benefit in patients with baseline elevated C-reactive protein (CRP).

Purpose

Our aim was to assess the association of CRP levels with 30-day and 1-year mortality in patients with acute myocardial infarction treated with primary PCI and with residual cholesterol risk.

Methods

The study included 1531 patients admitted for primary PCI, with the residual cholesterol risk, i.e. low-density lipoprotein cholesterol (LDL-C) levels of &gt;1.80 mmol/l (70 mg/dl), from a prospectively kept electronic registry of a high-volume tertiary center, for whom in-hospital CRP measurements were available. Elevated CRP was defined as ≥5 mg/l (local laboratory cut off value), measured during index hospitalization. Cox regression models were constructed to assess the impact of elevated CRP on 30-day and 1-year mortality.

Results

72% of the included patients with LDL-C &gt;1.80 mmol/l had elevated in-hospital CRP (n=1107). Compared with patients with CRP levels within reference limit, elevated CRP was associated with older age (62 vs. 60, p&lt;0.001), higher rates of diabetes (25.8% vs. 18.5%, p=0.002), renal failure (6.4% vs. 2.1%, p&lt;0.001) and Killip class &gt;1 at presentation (22.5% vs. 12.3%, p&lt;0.001), as well as lower EF (44% vs. 48%, p&lt;0.001) and lower haemoglobin on admission (13.9 g/dl vs. 14.2 g/dl, p&lt;0.001). Crude mortality rates were increased in patients with CRP ≥5mg/l at both 30 days (6.0% vs. 2.4%, p=0.003) and 1 year (13.2% vs. 6.3%, p&lt;0.001) (Figure). After adjusting for the observed baseline differences, CRP ≥5mg/l remained an independent predictor of mortality at 1 year (HR 1.691, 95% CI: 1.050–2.724, p=0.03), but not at 30 days (HR 1.690, 95% CI: 0.859–3.324, p=0.13).

Conclusion

In primary PCI-treated patients with residual cholesterol risk, elevated in-hospital CRP was independently associated with 1-year mortality. Our findings may thus suggest a potential window of opportunity, for anti-inflammatory therapies to improve outcomes beyond the acute phase.

Figure 1

Funding Acknowledgement

Type of funding source: None

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Background

Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients.

Methods

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (&gt;20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis &gt;75%).

Results

Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p&lt;0.000) and in cardiogenic shock (40% vs. 2.2%; p&lt;0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p&lt;0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions &gt;20mm (50% vs. 29%; p&lt;0.000), more intraluminal thrombus (86% vs. 45%; p&lt;0.000), greater number (1,48±0,9 vs. 1,28±0,7; p&lt;0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p&lt;0.000) and contrast media used (202±96 vs. 172±66; p&lt;0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p&lt;0.000), and one-year all-cause mortality (41% vs. 11%: p&lt;0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1).

Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance &lt;60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients.

Conclusions

Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and long-term mortality of patients with midrange ejection fraction undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Background

Previous studies associated midrange ejection fraction (mrEF) with impaired prognosis in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to assess clinical profile and short- and long-term mortality of patients with mrEF after STEMI treated with primary percutaneous coronary intervention (PCI).

Methods

This analysis included 8148 patients admitted for primary PCI during 2009–2019, from a high-volume tertiary center, for whom echocardiographic parameters obtained during index hospitalization were available. Midrange EF was defined as 40–49%. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard of mrEF, with the reference category being preserved EF (&gt;50%).

Results

mrEF was present in 29.8% (n=2 427), whereas low ejection fraction (EF&lt;40%) was documented in 24.7% of patients (n=2 016). mrEF was associated with a higher baseline risk as compared with preserved EF patients, but lower when compared with EF&lt;40%, in terms of prior MI (14.5% in mrEF vs. 9.9% in preserved EF vs. 24.2% in low EF, p&lt;0.001), history of diabetes (26.5% vs. 21.2% vs. 30.0%, p&lt;0.001), presence of Killip 2–4 on admission (15.7% vs. 6.9% vs. 26.5%, p&lt;0.001) and median age (61 vs. 59 vs. 64 years, p&lt;0.001). At 30 days, mortality was comparable in mrEF vs. preserved EF group, while it was significantly higher in the low EF group (2.7% vs. 1.6% vs. 9.4%, respectively, p&lt;0.001). At 5 years, mrEF patients had higher crude mortality rate as compared with preserved EF, but lower in comparison with low EF (25.1% vs. 17.0% vs. 48.7%, p&lt;0.001) (Figure). After adjusting for the observed baseline differences mrEF was independently associated with increased mortality at 5 years (HR 1.283, 95% CI: 1.093–1.505, p=0.002), but not at 30 days (HR 1.444, 95% CI: 0.961–2.171, p&lt;0.001).

Conclusion

Patients with mrEF after primary PCI for STEMI have a distinct baseline clinical risk profile, as compared with patients with reduced (&lt;40%) and preserved (≥50%) EF. Importantly, mrEF did not have a significant impact on short-term mortality following STEMI, but it did independently predict the risk of 5-year mortality.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of gender and young age in patients with acute myocardial infarction undergoing primary PCI

Background

Previous studies showed higher unadjusted mortality rates in female patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). However, after adjusting for differences in baseline characteristics, including age, female gender was not consistently associated with higher mortality.

Purpose

Our aim was to investigate the impact of gender on short- and long-term mortality in patients aged 18 to 55 years with AMI undergoing primary PCI.

Methods

We included 11 288 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard. Median follow up was 1 507 days.

Results

3 505 patients were younger than 55 years (31%). In this age group, 18.9% were female patients (n=661). Baseline characteristics were similar for females vs. males below the age of 55 years, including similar reperfusion times (338 min. vs. 341 min., p=0.8), with only exceptions being a higher rate of previous hypertension (64% vs. 58%, p=0.002) and stroke (3.6% vs. 2.2%, p=0.049), as well as lower ejection fraction (48% vs. 51%, p&lt;0.001), in female patients. MINOCA (Myocardial Infarction with Nonobstructive Coronary Arteries) was more frequently present in female vs. male patients aged ≤55 years (10.1% vs. 5.0%, p&lt;0.001). In the overall population, crude mortality was higher in female patients at 30 days (9.8% vs. 6.0%, p&lt;0.001) and 5 years (38.4% vs. 30.2%, p&lt;0.001). In younger patients (≤55 years), mortality rates were low and similar between the sexes at both 30 days (3.6% in females vs. 2.5% in males, p=0.136) and 5 years (14.5% vs. 13.4%, p=0.58). On the contrary, in patients aged &gt;55 years, crude mortality was higher in female patients at both 30 days (11.3% vs. 7.9%, p&lt;0.001) and 5 years (43.9% vs. 39.4%, p=0.02), albeit mainly driven by the differences in baseline characteristics between the sexes in this older age group (adjusted HR for female sex 1.220, CI95% 0.920–0.617, p=0.17, at 30 days; and adjusted HR 1.033, CI95% 0.908–0.175, p=0.62, at 5 years).

Conclusion

Differences in crude mortality rates between sexes in patients with AMI admitted for primary PCI appear to be mainly dependent on age, with similar rates of both short- and long-term mortality in younger patients (≤55 years). The observed excess in mortality in older (&gt;55 years) female vs. male patients could be explained by the differences in baseline clinical characteristics.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of atrial fibrillation in patients undergoing primary PCI with versus without left ventricular function impairment

Background

Atrial fibrillation (AF) and impaired left ventricular (LV) function have both been separately associated with increased risk of mortality following primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to comparatively evaluate the impact of LV dysfunction and AF on the risk of mortality in primary PCI-treated patients.

Methods

This analysis included 8561 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center, from whom echocardiographic parameters were available. LV dysfunction was defined as EF&lt;40%. Adjusted Cox regression models were used to assess 30-day and 1-year mortality hazard.

Results

AF was present in 3.2% (n=273), whereas 37% had LV dysfunction (n=3189). Crude mortality rates were increased in the presence of either AF or LV dysfunction, and were the highest in the group of patients having both AF and impaired LV function, at 30 days (1.8% in no AF and no LV dysfunction vs. 5.4% if AF only vs. 7.0% if EF&lt;40% only vs. 14.9% if AF and LV dysfunction concurrently present, p&lt;0.001) and at 3 years (10.5% if no AF and no LV dysfunction vs. 35.8% if AF only vs. 28.5% if EF&lt;40% only vs. 60.3% if AF and LV dysfunction both present, p&lt;0.001). After multivariable adjustment for other significant mortality predictors, including age, previous stroke, MI, diabetes, hyperlipidemia, anemia and Killip≥2, LV dysfunction alone and in combination with AF was an independent predictor of mortality at both 30 days (HR=2.2 and HR=2.5, respectively, p&lt;0.001 for both) and at 3 years (HR=1.9 and HR=2.9, respectively, p&lt;0.001 for both). However, presence of AF alone, in the absence of an impaired LV function, was not independently associated with mortality at 30 days (HR 1.34, CI 95% 0.58–3.1, p=0.48), but rather at 3 years (HR 1.74, CI 95% 1.91–2.54, p=0.004).

Conclusion

Atrial fibrillation is associated with long-term mortality in STEMI patients undergoing primary PCI, irrespective of the LV function. Conversely, short-term prognostic relevance of atrial fibrillation in STEMI is dependent on the presence of LV dysfunction.

Kaplan Meier curve_AF_LV dysfunction

Funding Acknowledgement

Type of funding source: None

Gender specific differences in functional capacity in asymptomatic patients with isolated severe aortic stenosis

 

Risk stratification as well as treatment decision in asymptomatic patients with isolated severe aortic stenosis (AS) is matter of ongoing debate. It has been known that gender-specific difference in left ventricular reaction to AS exists. Female gender has also been linked to increased risk of adverse events after surgical AVR but with better outcome after TAVI. We investigated whether there is a gender difference in functional capacity in asymptomatic patients with isolated severe AS.

Asymptomatic patients with severe AS were prospectively enrolled and underwent cardiopulmonary stress-echocardiography exercise testing (ESE-CPET) on supine ergobicycle, ramp protocol, 15 W/min. Patients with ischemia positive test were excluded (ECG and/or echo)

There were 139 patients, 61 women. There were no gender differences in age (66.36 vs 67.37, p=ns), echo parameters (Vmax 4.54 vs 4.48m/s, AVA 0.62 vs 0.68cm2, and Pmean 52.6 vs 53.8mmHg, all p=ns), LVEF (68.56 vs 70.90%, p=ns), e/E' (12.74 vs 14.45, p=ns), BNP (112.51 vs 110.55 pg/ml, p=ns) and valvulo-arterial impedance (4.65 vs 5.14mm Hg·ml–1·m2, p=0.07). Women had higher body mass index (29.05 vs 26.95, p=0.022), lower VO2max (12.96 vs 17.93 ml/kg/m2, p=0.001) and higher VE/VCO2 slope (33.69 vs 29.01, p=0.003). Univariable and multivariable linear regression analysis were used to test the relation between various clinical and echocardiographic parameters and VO2max. The variables independently associated with the VO2max are shown in table 1, with female gender being the strongest independent predictor of VO2max

Conclusion

Female gender is independent predictor of decreased functional capacity, even when adjusting for other variables, including BMI and echo markers of AS severity. Further studies are needed to determine whether this finding affects the course and outcome of the disease

Funding Acknowledgement

Type of funding source: None

Comparison of contrast induced nephropathy definitions and in-hospital mortality in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

Background

Contrast induced nephropathy (CIN) has been associated with increased mortality in patients with acute myocardial infarction (AMI). However, different definitions of CIN have so far been used.

Purpose

We aimed to compare predictive accuracy of the 2 contemporary CIN definitions in patients with AMI undergoing primary percutaneous coronary intervention (PCI).

Method

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 7987 pts who underwent primary PCI for AMI in whom creatinine measurements were available for analysis. CIN incidence was evaluated according to relative creatinine increases of ≥25% (CIN25) and ≥50% (CIN50) from baseline levels within 72 hours after intervention. The primary end point was in-hospital mortality.

Results

Overall, 1116 (13.9%), and 345 (4.3%) patients developed CIN25, CIN50, respectively. Crude in-hospital mortality rate was 3.9% (312 pts) in the overall population. Both definitions were independently associated with in-hospital mortality (CIN25 adjusted odds ratio (OR) 4.2, 95% CI 2.7–6.6; p&lt;0.001, and CIN 50 adjusted OR 8.2, 95% CI 4.9–13.9; p&lt;0.001). Comparison of ROC curves showed that only the addition of the CIN50 (and not CIN25) definition to the combined model of clinical predictors of in-hospital mortality, which included pre-intervention TIMI flow 0–1, cardiogenic shock on admission, baseline creatinine clearance, prior stroke, chronic occlusion of non-culprit artery, post-intervention TIMI flow 3, left ventricular ejection fraction and procedure time, improved prognostic accuracy of the model (Figure 1).

Conclusion

Only acute kidney injury according to the CIN50 definition, but not the CIN25 definition, offers additional prognostic information above and beyond the combination of baseline predictors of in-hospital mortality in patients with AMI undergoing primary PCI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI

Background

Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce.

Purpose

Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI.

Methods

The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days.

Results

Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p&lt;0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p&lt;0.001), stroke (10.3% vs. 5.9%, p&lt;0.001) and CABG (10.5% vs. 1.5%, p&lt;0.001), higher rates of renal failure (10.7% vs. 4.8%, p&lt;0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p&lt;0.001) and a lower ejection fraction (40% vs. 47%, p&lt;0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p&lt;0.001) and 5 years (54.6% vs. 27.9%, p&lt;0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p&lt;0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p&lt;0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p&lt;0.001; 2nd to 3rd year 6.2% vs. 2.8%, p&lt;0.001; 3rd to 4th year 7.4% vs. 3.0%, p&lt;0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1).

Conclusions

Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO.

Nonculprit CTO vs. no CTO

Funding Acknowledgement

Type of funding source: None

The importance of early and late ventricular arrhythmias detection and prediction in acute myocardial infarction

Background

Malignant arrhythmias, ventricular tachycardia or ventricular fibrillation (VT/VF) in acute myocardial infarction (AIM) carry ominous prognosis including sudden cardiac death (SCD). It is not clear whether the timing of VT/VF occurrence always affects the poor prognosis of patients with AMI.

Aim

To investigate the prognosis of patients who undergoing primary percutaneous coronary intervention (PCI) in accordance with timing of VT/VF and to find the power predictors of their occurrence.

Methods

307 consecutive patients in PREDICT-VT study (NCT03263949), 57.9±10.6 year old, 72.3% males were analysed. Of these patients, 27.7% had VT/VF from the symptoms onset, within 48 hours of AIM (early VT/VF group). 8.1% of patients had VT/VF after 48h, during one year follow up (late VT/VF group).

Results

The frequency of VT/VF occurrence was high between symptoms onset and the end of 2nd month and during 5th and 6th month of AIM. The parameters of conventional echocardiography were significantly impaired in late VT/VF group, as well as parameters of longitudinal strain (LS) (table). Moreover, the MACE (cardiovascular mortality, SCD, new infarction, emergency revascularisation, and hospitalized heart failure) was the highest in late VT/VF group (p=0.000). The most significant predictor of late VT/VF was systolic LS (cut off −12.72%, ROC 0.680, Sen 71%, Sp 64%, p=0.006).

Conclusions

Although late VT/VF occurrence after primary PCI were less frequent than early VT/VF occurrence, patients with late VT/VF had a very poor prognosis. The most power predictor of late VT/VF were systolic longitudinal strain.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Clinical Center of Serbia

Comparison of the FASTEST and the ZWOLLE risk scores for identification of very low-risk patients for all-cause mortality and MACE following primary PCI

Background

Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) can be considered for early discharge in order to reduce healthcare costs and improve resource utilization. Novel, simple, the FASTEST score, demonstrated additional prognostic value over guideline recommended ZWOLLE score in a derivation cohort, but robust data about external validation are lacking.

Purpose

We aimed to compare overall predictive ability and discriminating power in identification of low-risk patients of novel FASTEST score compared to validated ZWOLLE score.

Methods

From a high-volume, single-center, prospective registry, in a period from 2009–2019, we included STEMI patients who underwent successful pPCI in whom both, FASTEST (1 point added for: femoral access, age&gt;65, LVEF &lt;50, TIMI &lt;3, creatinine &gt;1.5 mg/dl; left main disease; and Killip≥2) and ZWOLLE (age, anterior infarct, Killip class, TIMI flow, ischemia time, 3 vessel disease) scores were both calculated. Predictive ability of scores for in-hospital, 30 days and 1 year mortality and hospital MACE was tested using ROC analysis and comparing AUC. Also, event rate was compared between low-risk patients as classified by FASTEST (score=0) or ZWOLLE (score≤3).

Results

We included 5650 patients (age 60.8±11.4, male (71%), anterior STEMI (44%) and femoral approach (81%)). Overall, mortality rates were 2.1%, 3.1% and 8.1% for hospital, 30 days and one-year. As Low-risk subjects, ZWOLLE identified broader proportion of population compared to FASTEST (67% vs. 5.5%) mainly due to high prevalence of femoral approach (FASTEST low-risk 30% in radial approach subset), still, later had numerically lower mortality rates at hospital (0.7% vs. 0.3% (only 1 pt); p=0.62), 30 days (1.3% vs. 0.7%; p=0.39) and at one-year (4% vs. 2%; p=0.14). Both scores showed similar and very good predictive ability for in-hospital (AUC 0.81 vs. 0.81; p=0.66) and 30 days mortality (AUC 0.79 vs. 0.77; p=0.29), while at one-year, discrimination of crude mortality by FASTEST trended, but didn't reach statistical significance compared to ZWOLLE score, respectively (AUC 0.77 vs. 0.75; p=0.07). FASTEST showed better prediction for composite endpoint of in-hospital MACE - death, stroke, reinfarction and bleeding BARC class 3 or higher (AUC 0.71 vs. 0.67; p&lt;0.000) (Figure 1).

Conclusion

Both the FASTEST and the ZWOLLE scores showed very good discriminating power for in-hospital, 30 day mortality and one-year mortality, yet the FASTEST score offered comparative advantage for prediction of in-hospital MACE and could be used to identify selected patients where an early hospital discharge can be considered.

ZWOLLE vs FASTEST ROC analisys

Funding Acknowledgement

Type of funding source: None

P963 Heart failure development in patients with preserved ejection fraction after STEMI: how frequent is It and can we predict it?

Aim

the current study is a sub-study of PREDICT-VT (NCT03263949). Its aim was to determine the incidence and predictors of HFpEF development in STEMI patients treated by pPCI.

Methods

in 264 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done and included multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec) and rotational LV mechanics. LV index of post systolic shortening for longitudinal strain (PSS LS) and for circumferential strain (PSS CS) were calculated as average of PSS over 18 LV segments. LV diastolic function was assessed according to the current ESC guidelines.

Results

From 264 patients enrolled in PREDICT-VT study, until now 195 patients completed one-year follow and among them 87 pts (46 %) had EF≥50%. From those patients during one-year follow-up 30 pts (30.3 %) develop HF: 3 pts NYHA class 3/ 4 and 27 pts NYHA class 2. Patients who developed HF (Group HF, n = 30) were older (62 ± 7 vs55 ± 11, p = 0.002), had lower E/A ratio (0.77 ± 0.25 vs 0.94 ± 0.32, p = 0.014), more commonly altered LV diastolic function (83 vs 60%, p = 0.028) compared with pts who remained in NYHA class I (Group none-HF, n = 57). There were no significant differences in LVEF, MI localisation, nor in WMSI between groups. Longitudinal and circumferential myocardial deformations did not differ significantly, except for more pronounced PSS LS on epicardial level in Group –HF (11.5 ±7.5 vs 8.3 ± 7.7%, p = 0.073). Rotation mechanic analysis revealed that Group –HF had increased (14.08 ± 5.5 vs 12.5 ± 5.4°, p = 0.202), but delayed twist (350 ± 69 vs 327 ± 68 ms, p = 0.139) with reduced magnitude of peak untwisting velocities (-88.58 ±34.16 vs -95.20 ± 39.75°/sec, p = 0.488). However, only statistically significant difference was increased magnitude of untwisting velocity during late diastole (-57.53 ± 30.61 vs -42.88 ± 27.78, p = 0.029). Significant univariate predictors of HF development were: older age (Exp (B)=1.08, CI 1.027-1.139, p = 0.03), E/A ratio (Exp (B) =0.130, p = 0.018, 95%CI 0.024-0.700), female gender (Exp (B)=2.933, 95% CI 1.163 -7.397, p = 0.023) and late-diastolic untwisting velocity (Exp (B)=0.983, 95%CI 0.967-0.999, p = 0.033). However, in multivariable analysis only older age (Exp B= 1.09, 95% CI 1.028-1.155, p = 0.004) and female gender (Exp B= 2.80, 95% CI 1.01-7.708, p = 0.046) remained significant predictors.

Conclusion

HF after STEMI in patients with preserved EF is not rare and probably substantially contributes to the total incidence HF after STEMI. However, its prediction remained challenging, with female gender and older age confirmed as its significant determinants.

P1381 The utility of left ventricle deformation in patients with myocarditis with midle-range and preserved ejection fraction

Background

Predicting malignant ventricular arrhythmias and heart failure in patients (pts) with acute myocarditis and middle-range and preserved EF is challenge Aim: to define whether quantification of myocardial mechanics in early, acute phase of myocarditis offers more information to predict six months outcome of patients.Methods: In the 36 consecutive pts with myocarditis, middle age 32.86 ± 12.04yr, 75% males, echocardiography exam was done 1-3 day of diseases, including conventional parameters and comprehensive speckle tracking LV deformation analysis with longitudinal (L), circumferential (C) strain (S;%), strain rate (SR, 1/sec) and rotational LV mechanics. Results: The most patients were present as infarct-like myocarditis (80.56%), the others patients were present as heart failure-like (11.11%) and arrhythmia-like myocarditis (8.33%). At admission 27 (90%) pts had chest pain, 20 (66.7%) pts had ECG changes, 15 (50%) pts had symptoms of heart failure, 5 (16.7%) pts had arrhythmias. Amount of edema and fibrosis assessed by cardiovascular magnetic resonance (CMR) and echo correlate significantly. Classical and conventional parameters of LV systolic function, and deformation were not significantly different between groups. However, mechanical dispersion index (IMD) of global LS and systolic S were significantly different between groups (p &lt; 0.05). Conclusion: Myocardial deformation imaging, like speckle tracking echocardiography, offers deeper insight into complex mechanical abnormalities during not only LV contraction but LV relaxation in longitudinal directions in patients with acute myocarditis.

Infarct-like Arrhythmia-like Heart failure-like p EF (%) 57.5 ± 5.42 54.7 ± 12.9 58.3 ± 6.8 NS GLS endo (%) -20.8 ± 2.59 -19.78 ± 2.27 -17.36 ± 5.65 NS GLS (mid (%) -18.31 ± 2.4 -17.31 ± 1.52 -15.3 ± 5.10 NS GLS epi (%) -16.15 ± 2.28 -15.20 ± 0.92 -13.55 ± 4.68 NS IMD LS (ms) 37.04 ± 7.71 33.04 ± 6.58 60.75 ± 38.56 0.008 CS endo (%) -26.39 ± 6.93 -21.59 ± 3.88 -25.17 ± 6.48 NS CS mid (%) -17.32 ± 6.77 -13.03 ± 2.07 -15.95 ± 4.41 NS CS epi (%) -10.99 ± 6.89 -7.13 ± 0.72 -9.53 ± 2.73 NS IMD CS (ms) 47.69 ± 8.86 41.43 ± 23.92 41.01 ± 20.51 NS IMD SL peak S* 12.27 (21) 13.96 (4) 20.28 (84) 0.042 *Median and range values are presented.

570 Myocardial deformation imaging after STEMI: can we better predict one-year mortality and heart failure development?

Aim

this study is a part of PREDICT-VT study (NCT03263949). The aim was to test whether deformation imaging based on spackle tracking echocardiography predict MACE (total mortality, HF hospitalization and NYHA class ≥3 development) better than conventional echocardiography and clinical parameters.

Methods

in 264 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done including LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec). LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strain were calculated as average of PSS over 18 LV segments.

Results

198 patients completed 1-year follow-up and 22 patients (11.1%) experienced MACE. Significant echo, clinical and laboratory predictors with the ROC analysis are listed in the table according to AUC .

Conclusion

peak systolic longitudinal and to a lesser degree peak systolic circumferential deformation predict mortality and HF development after pPCI better than conventional echo and even clinical parameters. From diastolic parameters only radial SR during atrial contraction was better MACE predictor compared to conventional echocardiography.

AUC p Cut-off Senz Spec Peak systolic LS epicardial layer 0.757 &lt;0.001 -11 75 63 Radial SR during atrial contraction 0.754 &lt;0.001 -0.63 65 80 Peak systolic LS mid-wall layer 0.750 &lt;0.001 -12.58 80 60 PSS LS endocardial layer 0.744 &lt;0.001 0.1409 70 61 Peak systolic CS endocardial layer 0.744 &lt;0.001 -18.08 70 67 Wall Motion Score Index 0.740 0.001 1.53 70 70 Peak systolic CS mid-wall layer 0.730 0.001 -13.66 80 60 Peak radial LV strain 0.722 0.001 14.08 80 60 Creatine kinase peak level 0.698 0.003 2155 64 73 LV EF 0.692 0.004 47.5 67 60 TAPSE 0.685 0.015 1.95 75 60 LA strain 0.676 0.012 18.33 63 64 Killip class 0.644 0.028

Coronary Microcirculation in Heart Failure with Preserved Systolic Function

BACKGROUND

The Heart Failure with Preserved Ejection Fraction (HFpEF) is defined as the preserved left ventricular ejection fraction (LVEF) with the signs of heart failure, elevated natriuretic peptides, and either the evidence of the structural heart disease or diastolic dysfunction. The importance of this form of heart failure was increased after studies where the mortality rates and readmission to the hospital were founded similar as in patients with HF and reduced EF (HFrEF). Coronary microvascular ischemia, cardiomyocyte injury and stiffness could be important factors in the pathophysiology of HFpEF.

METHODS

The goal of this work is to analyse the relationship of HFpEF and coronary microcirculation in previous studies.

RESULTS

The useful diagnostic marker of coronary microcirculation in HFpEF may be the parameters measured by transthoracic echocardiography (TTE), the coronary flow reserve (CFR), as well as fractional flow reserve (FFR) and quantitative myocardial contrast echocardiography (MCE). Cardiac magnetic resonance (CMR) imaging represents the diagnostic gold standard in HFpEF. Coronary microvascular dysfunction in the absence of obstructive coronary artery disease (CAD) is poorly understood and may be more prevalent amongst women than men. Troponin level may be important in risk stratification of HEpEF patients.

CONCLUSION

There are no precise answers with respect to the pathophysiological mechanism, nor are there any precise practical clinical assessment of and diagnostic method for coronary microvascular dysfunction and diastolic dysfunction. In accordance with that, there is no well-established treatment for HFpEF.

3269Impact of type 2 diabetes on incidence and phenotype of heart failure in patients with atrial fibrillation

Background

Type 2 diabetes (T2DM) portends adverse prognosis in patients with atrial fibrillation (AF). Whether T2DM independently increases the risk of incident heart failure (HF) in AF is uncertain. Also, HF phenotype developing in patients with vs. those without T2DM has not been characterised.

Purpose

In AF patients without a history of prior HF, we aimed to assess: 1) the impact of T2DM on the risk of new-onset HF; and 2) the association between T2DM and HF phenotype developing during the prospective follow-up.

Methods

We included diabetic and non-diabetic AF patients, without a history of HF. Baseline T2DM status was inferred from medical history, haemoglobin A1c levels and oral glucose tolerance test. Study outcome was the first hospital admission or emergency department treatment for new-onset HF during the prospective follow-up. The phenotype of new-onset HF was determined by echocardiographic exam performed following clinical stabilisation (at hospital discharge, or within a month after HF diagnosis). HF phenotype was defined as HFrEF (left ventricular ejection fraction [LVEF] <40%), HFmrEF (LVEF 40–49%) or HFpEF (LVEF≥50%). Cox regression analyses adjusted for age, sex, baseline LVEF, comorbidities, smoking status, alcohol intake, AF type (paroxysmal vs. non-paroxysmal) and T2DM treatment was used to analyse the association between T2DM and incident HF.

Results

Among 1,288 AF patients without prior HF (mean age: 62.1±12.7 years; 61% male), T2DM was present in 16.5%. Diabetic patients had higher mean baseline LVEF compared with nondiabetic patients (50.0±6.2% vs. 57.6±9.0%; P<0.001). During the median 5.5-year follow-up, new-onset HF occurred in 12.4% of patients (incidence rate, 2.9; 95% confidence interval [CI], 2.5–3.3 per 100 patient-years). Compared with non-diabetic patients, those with T2DM had a hazard ratio of 2.1 (95% CI, 1.6–2.8; P<0.001) for new-onset HF, independent of baseline LVEF or other factors. In addition, diabetic patients had a significantly greater decline in covariate-adjusted mean LVEF (−10.4%; 95% CI, −9.8% to −10.8%) at follow-up, compared with nondiabetic patients (−4.0%; 95% CI, −3.8% to −4.2%), P<0.001. The distribution of HF phenotypes at follow-up is presented in Figure. Among patients with T2DM, HFrEF (56.9%) was the most common phenotype of HF, whereas in patients without T2DM, HF mostly took the phenotype of HFpEF (75.0%).

Conclusions

T2DM is associated with an independent risk of new-onset HF in patients with AF and confers a greater decline in LVEF compared to individuals without T2DM. HFrEF was the most prevalent presenting phenotype of HF in AF patients with T2DM.

P1472Predicting significant ventricular arrhythmias in STEMI patients in middle-range and preserved EF

Background

Predicting malignant ventricular and sudden cardiac death (SCD) in STEMI patients with middle-range and preserved EF is challenge.

Aim

To identify the best parameters to predict composite end-point defined as secondary VF, sustained/non-sustained VT and sudden death, 48h after and during the first year of follow up after STEMI in patients with middle-range and preserved EF.

Methods

In the 192 consecutive STEMI patients (pts) 57.8±10.4yr, 69.9% males, in PREDICT-VT study (NCT03263949) treated with pPCI, with EF ≥40%, early echo (5±2 days) was done including conventional parameters and comprehensive speckle tracking left ventricle (LV) deformation analysis with longitudinal (L), circumferential (C) strain (S; %) strain rate (SR, 1/sec), index mechanical dispersion (IMD) and rotational LV mechanics.

Results

Thirteen patients (8.3%) reached the end-point. Classical parameters of LV systolic function, including LVEF, wall motion score index and parameters of diastolic dysfunction were not significant predictors of the malignant arrhythmias. IMD of late rotation rate (63.7 vs. 40.7ms, p=0.055) and late diastolic untwisting rate (−48.85 vs. −63.18°/s, p=0.059) had trend to become the significant predictors. CS in papillary muscle level in endo and mid layers predicted the primary end-point (endo: −20.5±11.8 vs. −24.9±4.6, mid: −14.6±3.9 vs. −17.0±2.1, epi: −10.1±3.3 vs. −11.8±1.8) (table).

Parameter of circumferencial mechanics ROC area 95% CI p Cutt-off Sens Spec PM endo (%) 0.302 0.146–0.458 0.038 −22.75 70 67 PM mid (%) 0268 0.153–0.383 0.015 −15.65 80 62

Conclusion

Myocardial deformation imaging offers deeper insight into complex mechanical abnormalities during LV contraction and relaxation in STEMI patients with middle-range and preserved EF that predicts serious arrhythmic events.

P4619Comparison of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores for predicting in-hospital bleeding in acute myocardial infarction patients undergoing primary PCI

Background

Considering clinical importance of bleeding complications in patients with acute myocardial infarction (AMI), bleeding risk stratification is a key part of the management of these patients. CRUSADE, ACTION and ACUITY-HORIZONS bleeding risk scores are available for predicting in-hospital major bleeding events in patients with acute myocardial infarction.

Purpose

We aimed to evaluate performance of the three above mentioned risk scores for predicting in-hospital bleeding events defined according to The Bleeding Academic Research Consortium (BARC) criteria.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 6505 consecutive patients with acute myocardial infarction who underwent pPCI were included in analysis. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Overall there were 372 (5.7%) bleeding events out of which 117 (1.8%) fulfilled stage BARC 3 or higher bleeding criteria. All three scores showed good model calibration as assessed by the H-Ls test and very good discriminative power for BARC 3 of higher bleeding events detection as assessed by C-statistics (Table 1 & Figure 1):

Bleeding events stage BARC 3 or higher were statistically highly related with higher in-hospital mortality (13.7% vs. 3.5%; p<0.000).

Table 1 Risk score H-L H-L p AUC 95% CI p CRUSADE 11.46 0.177 0.761 0.750–0.771 vs. ACUITY = ns vs. ACTION <0.000 ACUITY-HORIZONS 10.47 0.236 0735 0.724–0.745 vs. ACTION = ns ACTION 5.74 0.677 0.701 0.698–0.712

Figure 1

Conclusions

All three evaluated scores showed very good discriminative capacity for predicting BARC 3 or higher bleeding events in patients undergoing pPCI for AMI.

P5977Predicting significant ventricular arrhythmias in STEMI patients: never-ending challenge, still more place for myocardial deformation imaging?

Background

Malignant ventricular arrhythmias in STEMI patients carry ominous prognosis including sudden cardiac death (SCD). According to the current guidelines only EF<35%, 40 days after STEMI, is indication for ICD implantation. Recently, index of myocardial dispersion (IMD) estimated by myocardial deformation imaging (speckle tracking echocardiography) was documented to provide better risk stratification.

Aim

To define whether quantification of myocardial mechanics early after pPCI using modern echocardiography offers information more to predict malignant arrhythmias during the first year after STEMI.

Methods

In the 226 consecutive STEMI patients (pts) 57.8±10.4yr, 71.7% males, in PREDICT-VT study (NCT03263949) treated with pPCI early echo (5±2 days) was done including conventional parameters and comprehensive speckle tracking LV deformation analysis with longitudinal (L), circumferential (C) strain (S;%) and strain rate (SR, 1/sec) and rotational LV mechanics. ROC analysis was performed to identify the best parameters to predict composite end-point defined as secondary VF, sustained/non-sustained VT and SCD, 48h after pPCI and during the first year of follow up.

Results

Twenty two patients (9.7%) reached the end-point. Classical parameters of LV systolic function, including LVEF, wall motion score index; global, systolic LS, CS and parameters of diastolic dysfunction were not significant predictors of the malignant arrhythmias. Early L SR, systolic C SR, IMD of global rotation and late rotation rate predicted the primary end-point (table).

Parameter ROC area 95% CI p Cutt-off Sens Spec Longirudinal mechanics   SR E (1/sec) 0.687 0.577–0.796 0.019 0.69 64 65   IMD S (ms) 0.752 0.666–0.838 0.002 66.1 71 72 Circumferencial mechanics   SR S (1/sec) 0.732 0.613–0.852 0.002 −1.22 71 67 Rotational mechanics   Global IMD (ms) 0.329 0.177–0.481 0.036 82.9 63 62   Late rotation rate IMD (ms) 0.318 0.196–0.442 0.026 41.1 65 64

Conclusion

Myocardial deformation imaging offers deeper insight into complex mechanical abnormalities during LV contraction and relaxation in longitudinal, circumferential and rotational directions (impaired and asynchronous deformations) in STEMI patients and predicts serious arrhythmic events.

P5481Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Previous studies have indicated that patients with non-anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have a more favorable prognosis compared with anterior STEMI, especially in the short term.

Purpose

Our aim was to identify predictors of increased 30-day mortality in patients with non-anterior STEMI undergoing primary PCI.

Methods

This analysis included 8188 patients referred to primary PCI during 2009–2017, from a prospective electronic registry of a high-volume catheterization laboratory, for whom 30-day follow-up was available. Non-anterior infarction was defined as presence of ST-segment elevation in inferior and/or lateral ECG leads or true posterior MI. Multivariable Cox regression was used to assess the mortality risk at 30 days.

Results

59.4% (n=4863) of the included patients presented with a non-anterior STEMI. Mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI (4.2% vs. 8.3%, p<0.001). Older age (> median of 61, HR 2.2, p=0.002), baseline renal failure (eGFR <60, HR 4.0, p<0.001), Killip class ≥2 (HR 3.8, p<0.001), previous stroke (HR 1.8, p=0.004), non-culprit chronic total occlusion (CTO, HR 2.0, p<0.001) and final TIMI flow grade <3 in the infarct-related artery (HR 3.1, p<0.001) were independently associated with an increased risk of 30-day mortality in non-anterior STEMI. The presence of at least one of these high-risk factors was noted in 61.2% of patients with non-anterior STEMI and was associated with a significantly higher risk of 30-day mortality (HR 18.2, p<0.001), similarly to the overall risk associated with anterior STEMI (HR 22.9, p<0.001), as compared with patients with non-anterior STEMI but without any of the here identified high-risk factors (Figure).

Figure 1

Conclusions

Crude mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI. However, the majority of non-anterior STEMI patients had at least one of the high-risk factors (older age, previous CVI, baseline renal failure, Killip class ≥2, non-culprit CTO or final TIMI flow <3), which predisposed these patients to a similar increase in short-term mortality risk as in patients with anterior STEMI.

P950Synergistic impact of renal failure and left ventricular dysfunction on short- and long-term mortality in patients with STEMI undergoing primary PCI

Background

Impaired left ventricular function (LV) and renal failure (RF) have both been separately associated with increased risk of mortality in ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Purpose

Our aim was to comparatively evaluate the relative impact of LV dysfunction and renal failure (RF) on the risk of mortality in primary PCI-treated STEMI patients.

Methods

5878 patients admitted for primary PCI during 2009–2015, from a prospectively kept, electronic registry of a high-volume catheterization laboratory, were included in the analysis. LV dysfunction was defined as EF<40%, and RF as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 according to Cockcroft-Gault formula. Adjusted Cox regression models were used to assess 30-day and 3-year mortality hazard, with patients with EF≥40% and normal renal function serving as the reference group.

Results

RF was documented in 17.1% (n=1006), whereas 36.5% had LV dysfunction (n=2141). LV dysfunction and RF were separately associated with increased crude mortality rates, whereas the concurrence of both resulted in the highest mortality rate at 30 days (0.7% if no RF and normal EF vs. 5.4% if RF alone vs. 3.9% if EF<40% alone vs. 12.6% if both RF and EF<40%; p<0.001), and at 3 years (5.7% if no RF and normal EF vs. 29.0% if RF alone vs. 19.0% if EF<40% alone vs. 47.4% if both RF and EF<40%; p<0.001). After multivariable adjustment for other significant mortality predictors, such as age, previous stroke, diabetes, hyperlipidemia, anemia and Killip≥2, RF and LV dysfunction were associated with a comparable increase in mortality risk at 30 days (HR=4.1 and HR=3.7, respectively, p<0.001 for both) and at 3 years (HR=2.8 and HR=2.7, respectively, p<0.001 for both). Importantly, the combined presence of RF and low EF was independently associated with a marked increase in both 30- day (HR=6.5, 95% CI 3.7–11.4, p<0.001), and 3-year mortality (HR=4.3, 95% CI 3.3–5.6, p<0.001).

Kaplan Meier cumulative mortality curves

Conclusion

Apart from each being independently associated with an increased risk of mortality, the concurrence of renal failure and LV dysfunction had a synergistic negative impact on the prognosis of primary PCI-treated STEMI patients

P953Comparison of the original and updated ACTION risk scores for predicting in-hospital and one-year mortality in patients with acute myocardial infarction undergoing primary PCI

Background

The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With The Guidelines (GWTG) AMI mortality model and risk score (ACTION) were introduced in 2011 to predict in-hospital mortality. In 2016 score was updated to enable a more accurate assessment, but, up-to-date, external validation in direct comparison was not performed.

Purpose

We aimed to externally validate and compare the prognostic value of original and updated ACTION score for in-hospital and one-year mortality.

Method

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5615 consecutive patients who underwent pPCI were available for analysis. For each patient, original (O-) and updated (U-) ACTION scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality (follow-up available for 91%) were assessed. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Mortality rates for in-hospital and one-year mortality were 4.2% and 9.6%, respectively. Both scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1).

Net reclassification index (NRI=1.06) showed that 48% of patients with in-hospital event and 58% without event, had their risk recalculated with U-ACTION with Integrated Discrimination Improvement slope 9.1% higher than in first model.

Table 1 Risk score H-L H-L p value AUC 95% CI p value AUC 95% CI Significant p value O-ACTION 9.4 0.3 0.829 0.819 to 0.839 p<0.0001 0.781 0.769 to 0.792 p<0.0001 U-ACTION 10.9 0.2 0.918 0.911 to 0.925 0.838 0.827 to 0.848

Figure 1

Conclusion

Updated ACTION score enables better prediction of in-hospital and one-year mortality in patients undergoing pPCI for acute myocardial infarction, thus it can be used preferentially over the original ACTION score for assessment of short and long-term mortality risks of this population.

P5011Impact of guideline-recommended medical therapy at discharge on long-term mortality in patients with or without left ventricular dysfunction after primary PCI for STEMI

Background

Clinical practice guidelines provide class I recommendation for the use of angiotensin-converting enzyme inhibitors (ACE-I) and beta-blockers in patients with prior myocardial infarction and left ventricular (LV) dysfunction, whereas their use in patients without LV dysfunction is considered to be a class IIa recommendation.

Purpose

Our aim was to comparatively assess the impact of ACE-I and/or beta-blockers on 3-year mortality in patients with or without impaired left ventricular (LV) function undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

The analysis included 4425 patients admitted for primary PCI during 2009–2015 from a prospective, electronic registry of a high-volume tertiary center, who survived initial hospitalization, and for whom information on LV function and discharge medication were available. Patients were stratified according to LV systolic dysfunction, defined as LVEF <40%. Unadjusted and adjusted Cox regression models were created to investigate the impact of beta-blocker and/or ACE-I therapy on 3-year mortality.

Results

22.9% (n=1013) had LV dysfunction, 23.0% (n=1017) received either an ACE-I or a beta-blocker and 72.2% received both medications at discharge (n=3197). The concurrent use of both ACE-I and beta-blockers was not different in LVEF≥40% vs. LVEF<40% (72.4% vs. 71.7%, p=0.43). The use of at least one of the guideline-recommended medications was associated with a significantly lower 3-year mortality in both patients with LVEF≥40% (18.7% if neither was used, 11.2% if either a beta-blocker or an ACE-I were used and 9.4% if both were used, p=0.001), and LVEF<40% (55.4% if neither was used, 32.5% if either a beta-blocker or an ACE-I were used and 22.9% if both were used, p<0.001) (Figure). After adjusting for significant mortality predictors including older age, diabetes, hypertension, renal failure, previous stroke, Killip class ≥2 and non-culprit chronic total occlusion (CTO), the concurrent use of both a beta-blocker and an ACE-I remained independently associated with lower 3-year mortality in both patients with LVEF<40% (HR 0.30, p<0.001) and LVEF≥40% (HR=0.41, p=0.001). The use of a single agent was independently associated with lower mortality in patients with LVEF<40% (HR 0.45, p=0.002), but not in patients with LVEF≥40% (HR 0.61, p=0.07).

Conclusions

Guideline-recommended use of both a beta-blocker and an ACE-I in post-MI patients was associated with a lower 3-year mortality regardless of the LV function, whereas using only one of the two agents was associated with improved prognosis only in patients with LV dysfunction, but not in patients without LV impairment.

P849Comparison of long-term mortality risk assessed with recalculated (maximal) CADILLAC score vs. baseline (admission) CADILLAC score in STEMI patients undergoing primary PCI

Background

Since patients with STEMI have high rate of adverse events not only during hospital stay, but also during short and long-term follow–up, appropriate risk stratification is a key part of the management of these patients following hospital discharge. CADILLAC score was derived and subsequently validated as accurate clinical tool for identifying patients with heightened risk following index event.

Purpose

We aimed to compare predictive value of recalculated, maximal, (M-) CADILLAC score vs. baseline (B-) CADILLAC score for long-term mortality in hospital survivors.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5387 consecutive patients STEMI who underwent primary PCI were included in analysis. For each patient B-CADILLAC score was calculated, and for survivors, we recalculated M-CADILLAC score, incorporating changes in three variable score individual contributors (worsening of Killip class, anemia development and renal function deterioration). As in original score derivation, patients with cardiogenic shock were excluded from analysis. Discrimination of the two risk models was evaluated by the C-statistic, Net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) index.

Results

For 111 (2.1%) patients that died in-hospital, B-CADILLAC very well predicted the event (AUC 0.87, 95% CI 0.86–0.88; p<0.0001) (Figure 1A). For hospital survivors, both evaluated scores showed good discriminative ability for long-term mortality (11.7%) but recalculated M-CADILLAC score was statistically better predictor of long-term mortality, as assessed by C-statistics (Table 1 & Figure 1B):

NRI showed that 38% of patients were reclassified with M-CADILLAC with IDI slope 0.8% higher than in first model.

Table 1 4723 pts (follow-up=90% pts, 41±27 months) AUC 95% CI p B-CADILLAC 0.756 0.744–0.768 p=0.018 M-CADILLAC 0.776 0.754–0.779

Figure 1

Conclusions

Baseline CADILLAC score has very good predictive ability for in-hospital mortality, but recalculated, maximal CADILLAC score offers discriminative advantage in hospital survivors for prediction of long-term mortality in STEMI patients undergoing primary PCI.

P3125Five-year impact of immediate invasive strategy on clinical outcomes in patients with non-ST-segment elevation myocardial infarction: RIDDLE-NSTEMI study

Background

Most of the previous studies evaluated the impact of early versus delayed invasive intervention on clinical outcomes in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) in one-year period.

Purpose

The aim of this study was to assess whether the immediate invasive intervention influences the occurrence of death and new myocardial infarction (MI), specifically in patients with non-ST segment MI (NSTEMI) in long-term follow-up.

Methods

In The Randomized Study of Immediate Versus Delayed Invasive Intervention in Patients With Non ST-segment Elevation Myocardial Infarction (RIDDLE-NSTEMI) 323 patients with NSTEMI were randomized to either immediate (median time to intervention was 1.4 hours) or delayed invasive strategy (61.0 hours). The incidence of primary outcome -death or new MI at 30 days was lower in patients assigned to the immediate (n=162) than in patients assigned to the delayed (n=161) invasive intervention group (4.3% vs. 13%, respectively; p=0.008). Long-term follow-up of 5 years was available for 96.90% of the patients.

Results

At 5 years, the immediate invasive intervention was associated with lower rate of death or new MI, compared with delayed invasive strategy (15.8% vs 32.9%, respectively; p=0.00). The observed benefit of the immediate intervention was mainly due to an increased early reinfarction risk with the delayed strategy (2.5% vs 9.9%, p=0.001) with similar new MI rates beyond 30 days (5.9% in the immediate and 10.7% in the delayed group, p=0.130). Five-year mortality was 12.0% in the immediate invasive intervention strategy group, and 18.1% in the delayed strategy group (p=0.135).

Conclusion

Immediate invasive intervention in the patients with NSTEMI significantly reduces the early risk of new MI. However, the timing of invasive intervention appears not to have significant impact on the clinical outcome beyond 30 days.